Excimer laser system for correction of vision with reduced thermal effects

ABSTRACT

A apparatus and method for controlling an apparatus for removing tissue from the eye performs various types of corrections using a relatively large beam, but oscillating, or dithering, that being to prevent reinforcing ridges from being formed during the tissue removal process. Further, various types of correction, such as hyperopia and astigmatism correction, are performed using a large beam that is scanned over the area to be ablated using overlapping shots. Further, the epithelium in the area to be treated is removed using an infrared fluorescent dye to dye the epithelium, and then observing the fluorescent patterns from the epithelium area to be removed. Once a certain area is no longer fluorescent after laser shots, smaller shots are then applied, selectively removing the epithelium from the remaining regions. Again, the fluorescence patterns are observed, and the process is repeated until no epithelium remains. At this point, all of the epithelium is removed, and further a map is created of the initial epithelial thickness at each point in the area from which the epithelium was removed. Using two astigmatism correcting ablation patterns intersecting at an angle, a lens is created capable of correcting for myopia, hyperopia, and astigmatism. Further, overlapping shots using a relatively large fixed spot size provide for reduced thermal heating, ridgeless treatment patterns, reduced shot count, and simplified equipment.

This application is a continuation-in-part of U.S. patent applicationSer. No. 08/224,751 filed on Apr. 8, 1994, abandoned which is in turn acontinuation-in-part of PCT Application No. EP93/02667 filed on Sep. 30,1993, and designating the Untied States, which in turn claims priorityto German application no. P 42 32 915.9 filed on Oct. 1, 1992.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The invention relates to an apparatus for surgically modifying thecurvature of the eye cornea and a method of controlling the apparatus,and more particularly to an apparatus for smoothly correcting a varietyof corneal defects using a large, fixed spot size in an overlappingpattern that reduces thermal effects.

2. Description of the Related Art

Since the initial development of corrective lenses, 20 new and betterways of correcting defective eyesight have been developed. From thebifocal lens and extended wear soft contact lens to corneal incisionsand shaping, the field of ophthalmology has seen great advances inconvenience, safety, and accuracy in correcting a variety of sightdefects, including myopia, hyperopia, and astigmatism.

While corrective lenses still find wide general application,ophthalmologists are focussing on surgery to correct such defects. Oneof the most popular surgical techniques is radial keratotomy, in which asurgeon forms radial slits in the outer surface of the cornea, allowingthe cornea to re-shape and resulting in a modified cornea to correct thedeficiencies of the patient's sight. This technique has continued todevelop, but the advent of the laser and its introduction into the fieldof medicine have given rise to a new and potentially revolutionarymethod of eye surgery. Specifically, the development of the excimerlaser and its application to eye surgery has opened a new approach toophthalmological surgery.

The excimer laser produces coherent light of a very short wavelength ofaround 193 nm. At these wavelengths and the resulting high energies, theexcimer laser removes, or ablates, tissue at the molecular level withoutsignificant heating of adjacent tissue. Thus, rather than "burning" awaytissue, the excimer laser literally breaks the molecular bonds, and theablated tissue is ejected from the ablated surface leaving a relativelyunmarred surface to heal virtually scar-free. This aspect of the excimerlaser is now well known and is further described, for example, in U.S.Pat. No. 4,784,135 entitled "Far Ultraviolet Surgical and DentalProcedures," issued Nov. 15, 1988.

The word "excimer" in excimer laser was initially drawn from itsmolecular principal of operation. The excimer laser was initially basedon the lasing action of excited dimers, such as xenon, krypton, orfluorine in the form of Xe₂, Kr₂, or F₂. The word "excimer" as appliedto lasers is now a misnomer, as the most popular excimer laser used ineye surgery does not even use dimers--it uses argon fluoride. Theexcimer laser is also a pumped laser, in the sense that another laser isused to stimulate the lasing action of the argon fluoride mixture in thelaser cavity. "Excimer laser" has now come to be applied to an entiregroup of lasers with ultraviolet wavelengths below 400 nm.

When used in ophthalmological surgery, the excimer laser is preferablypulsed, as that allows for application of high energies without thermalheating. These pulses are very short bursts of high energy laser lightapplied to the cornea. For example, such a laser is typically pulsed atbetween 1 to 50 Hz with a 10 to 20 ns pulse duration. A drawback of theexcimer laser, however, is the energy density over the beam tends tohave both large and small scale inhomogeneities. The application of theexcimer laser for surgical procedures is described in U.S. Pat. No.4,784,135, entitled "Far Ultraviolet Surgical and Dental Procedures,"issued Nov. 15, 1988. For a historical background of the development andapplication of the excimer laser to ophthalmic surgery, see Chapter 1 ofthe Color Atlas/Text of Excimer Laser Surgery, © 1993 Igaku-ShoinMedical Publishers, Inc.

As early as 1983, researchers recognized the potential application ofexcimer laser light in reshaping the cornea. Since that time, a numberof systems have been developed to reshape the cornea, using a variety oftechniques such as variable sized circular apertures to correct formyopia, variable sized ring shaped apertures to correct for hyperopia,and variable sized slit shaped apertures to correct for astigmatism.These techniques collectively came to be known as photorefractivekeratectomy. It has been recognized that using such apertures to correctfor myopia, for example, a series of excimer laser shots usingprogressively smaller spot sizes could ablate away a portion of thecornea to effectively build a "corrective lens" into the cornea. Thesetechniques are discussed, for example, in U.S. Pat. No. 4,973,330,entitled "Surgical Apparatus for Modifying the Curvature of the EyeCornea," issued Nov. 27, 1990, and in U.S. Pat. No. 4,729,372, entitled"Apparatus for Performing Ophthalmic Laser Surgery," issued Mar. 8,1988. Those skilled in the art of laser ophthalmological surgery haveextensively developed the required exposure patterns using thesevariable size apertures to provide an appropriate amount of correctionto various degrees of myopia, hyperopia, and astigmatism, and acombination of these conditions.

These multiple aperture systems, however, suffer a number of drawbacks.They tend to be complicated and inflexible, requiring a number ofaperture wheels or masks and only providing standard forms of correctionfor myopia and hyperopia with circular symmetry and astigmatism withcylindrical symmetry. The human eye, however, tends to have more subtledefects. A system that could accommodate these defects and provide moreadaptable solutions, as well as a physically simpler components, wouldthus be advantageous.

An apparatus for ablating tissue from the eye is shown in U.S. Pat. No.4,973,330, referenced above. This apparatus includes an excimer laser,the laser beam of which impinges on the cornea, with the axis of thelaser beam coinciding with the optical axis of the eye. Furthermore, afield stop limits the area of the laser spot on the cornea illuminatedby the laser beam, and the size of this field stop is set in atemporarily variable manner according to the profile of the area to beremoved so that the thickness of the area to be removed is a function ofthe distance from the optical axis of the eye.

The system described in U.S. Pat. No. 4,973,330 permits in this waysetting the "laser energy deposited" on the cornea as the function ofthe distance from the optical axis of the eye, but only under thecondition that the distribution of energy (i.e., the power of the laserbeam spot) is homogeneous, or at least axially symmetrical. This,however, is a condition that excimer lasers in particular do not alwaysfulfill. Inhomogeneous power distribution results in non-axiallysymmetrical removal. Moreover, the system described in U.S. Pat. No.4,973,330 only permits the correction of spherical aberrations, notastigmatism.

An apparatus based on the same fundamental idea is known from U.S. Pat.No. 4,994,058, entitled "Surface Shaping Using Lasers", issued Feb. 19,1991. That apparatus employs a "destructible field stop mask" instead ofa field stop having a temporarily variable aperture.

Another class of apparatus for shaping the cornea by means of removingtissue is known from the various L'Esperance patents. These include U.S.Pat. No. 4,665,913, entitled "Method for Ophthalmological Surgery,"issued May 19, 1987; U.S. Pat. No. 4,669,466, entitled "Method andApparatus for Analysis and Correction of Abnormal Refractive Errors ofthe Eye," issued Jun. 2, 1987; U.S. Pat. No. 4,718,418, entitled"Apparatus for Ophthalmological Surgery," issued Jan. 12, 1988; U.S.Pat. No. 4,721,379, entitled "Apparatus for Analysis and Correction ofAbnormal Refractive Errors of the Eye," issued Jan. 26, 1988; U.S. Pat.No. 4,729,372, entitled "Apparatus for Performing Ophthalmic LaserSurgery," issued Mar. 8, 1988; U.S. Pat. No. 4,732,148, entitled "Methodfor Performing Ophthalmic Laser Surgery," issued Mar. 22, 1988; U.S.Pat. No. 4,770,172, entitled "Method of Laser-Sculpture of the Opticallyused Portion of the Cornea," issued Sep. 13, 1988; U.S. Pat. No.4,773,414, entitled "Method of Laser-Sculpture of the Optically usedPortion of the Cornea," issued Sep. 27, 1988; and U.S. Pat. No.4,798,204, entitled "Method of Laser-Sculpture of the Optically usedPortion of the Cornea," issued Jan. 17, 1989. In that apparatus, a laserbeam with a small focus spot is moved by a two-dimensional scanningsystem over the area to be removed. This apparatus, which operates as a"scanner," has the advantage that it can generate any two-dimensionalprofile of deposited energy "over the area to be removed." Because ofthe small size of the beam spot, the period of treatment, however, isvery great, as power per area unit cannot be raised above a specific"critical" value.

Thus, current techniques do not adequately address the non-linear energydistribution of an excimer laser. The excimer laser includes both largescale and small scale non-linearities in its energy distribution. Thiscan cause over-ablation and under-ablation of certain areas of the eyeunder treatment. Thus it would be desirable to provide a system thatfurther homogenizes the effective energy deposited on the eye.

Systems that use apertures to create a series of progressively smallershot sizes also suffer from the disadvantage of creating sharp ridges inthe treatment zone of the cornea. Especially near the periphery of thetreatment zone, a number of shots are typically required to create thenecessary ablation depth at each particular spot size. The typicalablation depth for each shot is 0.2 μm. When multiple shots are requiredat a single aperture size, the ridge depth reinforces, creating aneffective ridge of some multiple of 0.2 μm. For example, five shotswould result in a ridge height of 1.0 μm. These sharp ridges in thetreatment zone can lead to unwanted epithelial regrowth, especially whencorrecting high diopter defects. A system that minimizes such ridgeswould promote smoother epithelial healing, preventing excessive regrowthand allowing the corrected eye to retain its correction for a longerperiod of time and with more stability.

Before ablating, most current excimer techniques also require physicallyscraping away the epithelial layer from the eye. This can be a traumaticprocedure for the patient, and requires a high degree of precision bythe surgeon. Alternative, less invasive methods of removal of theepithelium before ablation of the cornea are thus desirable.

Another problem with current techniques involves "central islands"created during the ablation process. A central island is an area of anablation profile which is not ablated to a depth proportional to thenumber of excimer laser shots fired on that particular area. Forexample, in typical myopia patterns, the greatest depth of ablation isat the center of the pattern. In ablating such patterns, a recurringproblem is that the central area is not ablated to as great a depth asis needed to create the proper ablation profile. The causes of thisproblem are not clear. However, techniques which reduce or eliminatethis problem are highly desirable.

Further, present systems typically use either a relatively small spotsize of less than 0.50 mm, or variable spot sizes that require the spotsize to be adjusted throughout the treatment. A relatively small spotsize has serious disadvantages, because it greatly increases the numberof shots required to complete a treatment. A variable spot size also hasdisadvantages, in that it requires complex masking instrumentation toallow the spot size to be adjusted. Reducing or eliminating either ofthese problems would be greatly desirable.

Another problem that has become apparent is thermal heating. Although anexcimer laser is a "cold" laser, which functions by breaking molecularbonds rather than by burning, repeated shots at a particular locationwill cause the tissue to heat. This limits the maximum shot rate allowedat a particular location. This in turn has historically causedtreatments to take at least a certain amount of time, because themaximum shot rate could not be exceeded. Eliminating this limitationwould similarly be desirable.

SUMMARY OF THE INVENTION

The method and apparatus according to the invention provides cornealcorrection using laser "polishing" or "dithering" in which subsequentshots used to ablate the eye are randomly or otherwise moved from acenter axis of treatment to prevent the formation of large ridges in thetreatment zone.

Further according to the invention, instead of using various apertureshapes, a relatively large beam is moved along the line of hyperopic orastigmatic correction desired, creating a line of overlapping shots. Iffurther correction is necessary, overlapping lines are then createdusing various beam sizes, thus forming the desired correction curve inthe cornea.

Further according to the invention, using this scanning beam technique,various non-symmetrical optical defects are corrected, such as a"curved" astigmatism, by modifying the line of travel of the overlappingshots or by otherwise generating a sequence of shots to appropriatelyablate a non-symmetrical defect.

Further in the system and method according to the invention, theepithelium is removed using laser ablation. The epithelium is first dyedwith an infrared fluorescent dye. The epithelium is then continuallyablated using a beam covering the area of epithelium to be removed untilan infrared scanning device recognizes that some portion of theepithelium is gone, as indicated by a lack of fluorescence. Then, eithermanually or under computer control, the spot size is reduced and areasthat still fluoresce are ablated until they no longer fluoresce. This isrepeated until the epithelium has been removed from the entire treatmentarea. This technique can also map the initial thickness of theepithelium before removal.

Further in the system and method according to the invention, myopia istreated by creating a lens formed by two astigmatism correcting ablationpatterns at an angle to one another. Preferably, this pattern isdeveloped by creating two astigmatism ablation patterns at right anglesto each other. Further, according to the invention, each of theseastigmatism ablation patterns is preferably created with a series ofoverlapping lines of shots.

The system and method according to the invention further provides atechnique for using relatively large overlapping shots of a fixed sizeto accomplish a desired treatment pattern. According to the invention, aseries of rings are calculated, in which each ring has a series of shotsfired along the radius of the ring. Using an empirical algorithm, thenumber of shots, the distance of each ring from the center of thedesired treatment area, and the optimal fixed shot size is determined.According to another embodiment, a shot dithering pattern is used todistribute the large, overlapping shots throughout the treatment area.These techniques have a number of advantages, including allowing largeoverlapping shots, thus reducing treatment time, and reducing theformation of large ridges that would be encountered in a treatmentpattern in which the shots were centered on the treatment area. Thisridging effect is even further reduced by placing these shots in aspiral pattern.

Further according to the invention, thermal heating is reduced. This isachieved by optimally adjusting the order in which the needed shots arefired. Typically, a single tissue location can only absorb a certainnumber of shots per second. According to the invention, however,subsequent shots in the treatment pattern are fired at differentlocations that are not overlapping. Then, the desired partiallyoverlapping shot is later fired overlapping the first location. Forexample, a first shot is fired on one side of the treatment area, asecond, nonoverlapping shot is fired on the other side of the treatmentarea, and then a third shot is fired partially overlapping the firstshot. In another embodiment, the shot treatment array is sorted tomaximize the distance between sequential shots. Alternatively, the arrayis randomly reordered, thus statistically reducing the number ofoverlapping sequential shots. It will be appreciated that the effectiveshot rate can be doubled, because a particular point of tissue is onlybeing ablated on every other shot. By displacing the shots from eachother, even higher shot rates can be realized.

Calculating the shot patterns needed using a fixed large spot size isnontrivial, generally not easily derived. Therefore, further accordingto the method and apparatus of the invention, the shot patterns aredetermined through an empirical search algorithm, which searches forappropriate rings of shots to ablate the desired pattern.

Further, according to the invention, shots are preferably fixed at asize between 2.0 and 3.5 mm. This minimizes the number of requiredshots, while providing the resolution necessary to ablate virtually anydesired pattern.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the present invention can be obtained when thefollowing detailed description of the preferred embodiment is consideredin conjunction with the following drawings, in which:

FIG. 1A is a simplified diagram illustrating a typical excimer laser eyesurgery system in which can be implemented the apparatus and methodaccording to the invention;

FIG. 1B is a more detailed diagram illustrating the system of FIG. 1A;

FIGS. 1C and 1D are a side view and an end view, respectively, of analternative mirror arrangement to that shown in FIGS. 1A and 1B;

FIG. 2A is a view along the center axis of the treatment zoneillustrating a typical large beam ablation pattern to correct formyopia;

FIG. 2B is a side profile of FIG. 2A, further illustrating the use oftransition zones;

FIG. 3A is a view along the center axis of the treatment zoneillustrating random dithering according to the invention;

FIG. 3B is a view along the center axis of the treatment zoneillustrating circular dithering according to the invention;

FIGS. 4A and 4B are illustrations showing a shot pattern for astigmaticcorrection according to the invention;

FIG. 5 is an illustration of a treatment zone illustrating a shottreatment pattern for a curved astigmatism according to the invention;

FIG. 6A and 6B are illustrations showing a shot pattern for treatment ofhyperopia according to the invention;

FIGS. 7A and 7B are side profiles of the cornea illustrating initial andending radii of curvature over a treatment zone for correction of myopiaand hyperopia;

FIG. 8 is an illustration of shot patterns used to correct for generalnon-symmetrical aberrations of the eye according to the invention;

FIG. 9 is a flowchart illustrating a calculation routine used to performcorrection for astigmatism, hyperopia, and myopia using the random orcircular dithering and large beam scanning according to the invention;

FIGS. 10A, 10B, and 11 are flowcharts illustrating an astigmatismroutine used by the calculation routine of FIG. 9;

FIG. 12 is a flowchart illustrating a hyperopia routine used by thecalculation routine of FIG. 9;

FIG. 13 is a flowchart of a random dithering routine used by thecalculation routine of FIG. 9;

FIG. 14 is a flowchart of a circular dithering routine used by thecalculation routine of FIG. 9;

FIGS. 15 and 16 are views along the axis of treatment of the eyeillustrating ablation of the epithelium according to the invention;

FIG. 17 is a perspective view of a lens ablation pattern according tothe invention created by ablating two orthogonal astigmatism correctingablation patterns;

FIG. 18A is a top view of the ablation pattern of FIG. 17;

FIGS. 18B and 18C are side views of a portion of the ablation pattern ofFIG. 18A;

FIG. 19 is an illustration of a shot pattern according to the inventionusing a constant spot size of 2.0 mm to correct -5 diopters using aspiral shot dithering pattern according to the invention;

FIG. 20 is an illustration of a shot pattern according to the inventionusing a constant spot size of 2.0 mm to correct -5 diopters using aslightly different form of spiral shot dithering pattern according tothe invention;

FIG. 21 is an illustration of a shot pattern according to the inventionusing a constant spot size of 4.25 mm to correct -5 diopters using thesearch algorithm according to the invention;

FIG. 22 is an illustration of a shot pattern according to the inventionusing a constant spot size of 2.0 mm to correct -7 diopters using thesearch algorithm according to the invention;

FIG. 23 is an illustration of a shot pattern according to the inventionusing a constant spot size of 2.0 mm to correct +5 diopters using thesearch algorithm according to the invention;

FIGS. 24A, 24B, and 24C are enumerations of each shot used to create thepattern of FIG. 21 sorted by X position order, the X position and Yposition being given in microns;

FIG. 25 is a diagram illustrating how concentric rings of overlappingspots are calculated according to the invention;

FIG. 26 is a diagram illustrating how concentric rings of overlappingspots are created with each sequential shot not overlapping with theimmediately previous shot;

FIG. 27 is a flow chart illustration of a search routine used togenerate shot patterns according to the invention; and

FIG. 28 is a flow chart illustration of a shot dithering routine used togenerate shot patterns according to the invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT

FIG. 1A, according to the invention, shows an excimer laser 20 providinga beam to a beam homogenizer 24 that also includes focusing components.The beam homogenizer 24 then provides a relatively homogeneous beam 22to a field stop in the form of a diaphragm 36, which is regulated by acontrol unit 64 in such a manner that it limits the laser spot on an eye44 to an area the maximum size of which is between approximately 10% andapproximately 90% of the area of the region in which the tissue is to beremoved when ablation is performed to correct for astigmatism orhyperopia. This preferred maximum size is more dependent on the shapeand size of the area to be ablated rather than any fixed percentage, andcould be, for example, between 20% and 80%. The larger the size of thespot that can be used the better, as that reduces treatment time.

Moreover, a beam manipulator unit in the form of a scanning mirror 42 isprovided that also is regulated by the control unit 64. The scanningmirror 42 moves the axis of the beam 22 over at least a part of theregion on the eye 44 in which the tissue is to be removed.

The invention thus provides an eye surgery system 10 for shaping thecornea by removing tissue with which removal of non-axially symmetricalprofiles can be realized in a relatively shorter time. Further, the eyesurgery system 10 compensates for any inhomogeneous distribution ofenergy over the beam spot.

By this means, not only can a very small spot be illuminated, as in thecase of a scanning unit, but also a relatively large region can beilluminated so that the treatment can occur relatively quickly. Toshorten treatment time, it is preferred to maintain the size of thelaser spot on the eye 44 as large as possible for as long as possible,for example to at least 50% of the size of the region to be treated.

The scanning mirror 42 can, by way of illustration, tilt about or aroundat least one axis. Mirror elements that can be used, and in particularthat can be tilted about two axes, are described in U.S. Pat. No.4,175,832, for example.

Further, the control unit 64 can regulate the size of the laser spot onthe eye 44 in correlation to the movement of the beam axis (through useof the scanning mirror 42) on the eye 44, thus precisely regulating theenergy deposited on a specific area of the eye 44. Thus, non-axiallysymmetrical profiles can be generated on the corneal surface of the eye44. Different types of diaphragms 36 can be used, for example ovals orcircles with blocked centers.

Moreover, the scanning mirror 42 can be placed in the beam 22 not onlyafter the diaphragm 36, but also before the diaphragm 36. It would thenbe preferable to move the diaphragm 36 synchronously with the scanningmirror 42.

In correcting spherical aberrations, the control unit 64 preferablymoves the scanning mirror 42 such that the beam 22 oscillates from shotto shot in at least one direction, such as is illustrated by an arrow12. Such oscillation compensates for inhomogeneity of the energydistribution over the beam 22. This oscillation finds applicationregardless of the maximum beam size.

To correct astigmatism, the scanning mirror 42 moves the axis of thebeam 22 between at least two directions, neither of which are collinearwith the axis of treatment of the eye 44. This permits treating anastigmatic eye, which, without being limited by theory, the latestresearch states has not one apex, but two. That is, it has the shape ofcamel humps. Also, the control unit 64 regulates the scanning mirror 42such that the axis of the beam 22 oscillates at least one-dimensionallyabout each direction, thus compensating for homogeneity of the beam 22.

To correct for hyperopia, the axis of the beam 22 is preferably moved ona conic-shaped shell surface, it also being possible to superimpose anat least one-dimensional oscillation to compensate for inhomogeneity ofthe beam 22. By moving on a conic-shaped shell surface, a circularpattern of overlapping shots are projected onto the eye 44.

In adapting the diaphragm 36 to the typical shape of the cross-sectionof excimer laser beams, the diaphragm 36 may also have a non-axiallysymmetrical shape, with the diaphragm 36 being turned in order tohomogenize the deposited energy during the movement of the axis of thebeam 22 on the conic shell. The homogenization is enhanced if theturning of the diaphragm 36 occurs asynchronously to the rotation of theaxis of the beam 22 on the conic shell.

FIG. 1B shows additional details of the typical eye surgery system 10 inwhich the method and apparatus according to the invention would beimplemented. An excimer laser 20 provides a pulsed beam 22 to a beamhomogenizer 24 after reflection from optics 26. A shutter 28 is alsoprovided to block transmission of the pulsed beam 22 to the beamhomogenizer 24. The excimer laser 20 is a typical excimer laser as iswell known in the art. It preferably provides a 193 nm wavelength beamwith a maximum pulse energy of 400 mJ/pulse. The excimer laser 20preferably provides maximum power at the treatment site of 1 W, with apulse frequency of 10 Hz and a pulse length of 18 ns. Of course avariety of other excimer lasers could be used, and the apparatus andmethod according to the invention further have application where a laserother than an excimer laser is used. By way of example, the wavelengthof the light from the laser is preferably less than 400 nm, as thatprovides the desired ablating action with reduced thermal heating.Further, other pulse energies can be provided, such as all the way downto 200 mJ/pulse, with typical repetition rates of 60 to 100 pulses persecond with a typical pulse length of 10 to 30 ns. Again, all of theseare merely typical values, and deviation from them can be made withoutchanging the spirit of the apparatus and method according to theinvention. Further examples of such laser systems can be found in U.S.Pat. No. 4,665,913, entitled "Method for Ophthalmological Surgery,"issued May 19, 1987, and U.S. Pat. No. 4,729,372, entitled "Apparatusfor Performing Ophthalmic Laser Surgery," issued Mar. 8, 1988.

The beam homogenizer 24 preferably includes standard homogenization andfocusing hardware, which can be based both on optical mixing of the beamand on rotation of the beam. For an example of typical beamhomogenization hardware, see U.S. Pat. No. 4,911,711 entitled,"Sculpture Apparatus For Correcting Curvature Of The Cornea," issuedMar. 27, 1990. Note that by providing the "dithering" according to theinvention as discussed below, the beam homogenizer 24 can be simplerthan the beam homogenization hardware shown in that reference. From thebeam homogenizer 24, the pulsed beam 22 is then reflected off of optics30, which also passes a red pilot laser beam from a pilot laser 32. Thispilot laser 32 is preferably a 633 nm helium neon laser of less than 1mW of power. The red pilot beam from the pilot laser 32 can also beblocked by a shutter 34. The pilot laser 32 is aligned so that itsoptical pathway coincides with the pulsed beam 22. The pilot laser 32provides the functions of centering the beam 22 on the axis of treatmentof the eye 44, and also provides for focusing on the eye 44, as isdiscussed below. Further, it can provide an optical fixation point forthe patient, although a different laser or light source could also beprovided for that purpose.

From the optics 30, the pulsed beam 20 (now also co-aligned with thebeam from the pilot laser 32) then passes through an adjustablediaphragm 36, which allows the beam size to be adjusted before it entersthe final optics. After the diaphragm 36, a spot mode lens 38, when inplace, provides further concentration of the beam 22, allowing spotablation of certain defects in the eye by a physician performingtherapeutic rather than refractive surgery. The spot mode lens 38 isthus moved into and out of place depending on whether therapeutic orrefractive treatment is desired.

Following the spot mode lens 38, a focusing lens 40 directs the beam 22onto the scanning mirror 42, which then reflects the beam 22 onto apatient's eye 44. Note that the portion of the beam 22 from the pilotlaser 32 is used for both adjusting the distance of the eye 44 from theentire eye surgery system 10 and for providing centering, as will bediscussed below. The focusing lens 40 focuses light such that when theeye 44 is at the optimal distance, the beam 22 is properly focused ontothe eye 44.

These various lenses and mirrors thus combine to form an optical systemproviding an excimer beam to the cornea. The optical system creates alaser spot on the cornea, and the spot size is adjustable, along withits location. It will be readily appreciated that a wide variety ofdifferent systems could be used to optically provide such a beam. Forexample, a lens could be used to adjust the spot size rather than anaperture, and instead of a scanning mirror, the patient or the patient'seye 44 could be physically moved to provide for shots at differentlocations on the eye 44.

Also provided in the system according to the invention is a focusinglaser 46, whose beam can also be blocked by a shutter 48. The focusinglaser 46 is preferably a green helium neon laser providing a beam of awavelength of 535 nm and less than 1 mW of power. The beam from thefocusing laser 46 travels through optics 50 and impinges on the eye 44at an angle. The distance of the eye 44 from the eye surgery system 10is adjusted such that both the beam from the pilot laser 32 and the beamfrom the focusing laser 46 impinge on the surface of the eye 44 at thesame point.

Further provided is an optional fixation mask 52, which is well known inthe art and is used to stabilize the eye 44 during surgery. It caninclude debris removal components, and is typically attached to the eye44 through either a vacuum suction ring or through hooks. A clean gaspurge unit 54 ensures that the optics and the beams in the system arefree from any floating debris.

A microscope 56 is provided for the physician to observe progress duringablation of the surface of the eye 44. The microscope 56 is preferably aZEISS OPMI "PLUS" part No. 3033119910, with magnifications of 3.4, 5.6and 9.0 times. Field illumination is provided by a cold light source notshown, which is preferably the Schott KL1500 Electronic, ZEISS partnumber 417075. This microscope 56 focuses through the scanning mirror 42and also focuses through a splitting mirror 58. The splitting mirrorfurther provides a view of the eye 44 to an infrared video unit 60,which is used for the epithelial ablation discussed below. The infraredvideo unit 60 preferably provides an image output to a capturing videoscreen 62 and to a control unit 64. The infrared video unit 60 ispreferably sensitive to both infrared light and visible light.

The control unit 64, which is typically a high performance computercompatible with an IBM PC by International Business Machines Corp.,further preferably controls all components of the eye surgery system 10,including the shutters 28, 34, and 48, the diaphragm 36, the spot modelens 38, and the scanning mirror 42.

FIGS. 1C and 1D illustrate an alternative mirror arrangement to that ofthe mirror 42 of FIGS. 1A and 1B. Instead of using the single mirror 42,two mirrors 80 and 82 are used in the path of the beam 22 to ablate theeye 44.

The first mirror 80 is mounted on an axis 84 that provides foradjustment of the beam in one direction, while the second mirror 82 ismounted on an axis 86 that allows adjustment of the beam in a seconddirection. When the first mirror 80 is adjusted, for example, the beam22 adopts an alternative beam path 88, which strikes the second mirror82 at a different position, subsequently adjusting the position of thebeam 88 onto the eye 44. This is seen in FIG. 1C. The other axis ofadjustment is provided by the second mirror 82. Referring to FIG. 1D itis seen that when the second mirror 82 is adjusted, the beam 22 takes analternate beam path 90, thus allowing the beam to be moved in the secondaxis.

These two mirrors thus combine to allow the beam to be aimed anywhere onthe eye 44. This combination of mirrors allows for mounting with asingle axis of rotation, rather than the double axis of adjustmentrequired by the mirror 42. This can simplify implementation of theoptics of the excimer laser system 10. The mirrors are adjusted usingservo motors coupled to the axis 84 and 86, with those servo motors notbeing shown.

FIG. 2A shows a simplified top view of the cornea of a typical eye 44 onwhich myopic correction has been performed. A treatment zone 100 of awidth S is centered on an axis of treatment 102, which does notnecessarily correspond to the optical axis of the eye 44. The treatmentzone 100 is bounded by a first outer ablation ring 104, with subsequentablation rings 106 to 114 shown spaced more widely towards the center ofthe axis of treatment 102 (note that preferably the smaller shots areperformed first).

This wider spacing is topographical in effect, as in a typical system,the change in spot radius between shots may actually be constant, butwith a greater number of shots performed toward the periphery of thetreatment zone 100. Although only six ablation zones are shown, in atypical ablation pattern a greater number of spot sizes are used, and agreater number of shots are also performed. The ablation function forcalculating the necessary depth of ablation for myopia is discussedbelow in conjunction with FIG. 7A.

In performing high dioptric correction for myopia, using the standardablation function discussed below may result in an excessive depth ofablation along the axis of treatment 102. As illustrated in FIG. 2B, thestandard equation for myopic ablation would result, for example, in acurve 120 which would lead to a high depth of ablation along the axis oftreatment 102, and would also result in sharp edges 122 at the corner ofthe treatment zone 100. For simplicity, FIG. 2B shows the effect oftreatment on a flat surface rather than the surface of the cornea. Forsuch a high degree of correction, the use of transition zones cansignificantly reduce the edge effects in healing and can also reduce thecenter depth of ablation along the axis of treatment 102. Thesetransition zones 124 and 126 effectively create a multi-focal lens. InFIG. 2B, two transition zones 124 and 126 are shown resulting in ashallower ablation curve 128. The first of these transition zones 124 iscreated by performing a myopic ablation over the full width S of thetreatment zone 100 using a lesser degree of correction than the ultimatecorrection desired. Only those shots of a radius falling into the radiusof the transition zone 124 are performed, however, thus leaving auniformly ablated surface inside transition zone 124 for furthertreatment. This results in an initial curve 130.

Then, another series of myopic ablation shots using the myopic ablationfunction discussed below is performed using a somewhat greater degree ofcorrection but using a smaller "treatment zone" (in actual practice, thesmaller shots are preferably performed first). This resulting curve anduniformly ablated area 132 creates the second transition zone 126.Finally, a series of shots are performed for the full desired correctionbut using an again narrower zone of treatment, resulting in the finalcurve 134. The use of transition zones is known to the art ofphotorefractive keratectomy, and is described, for example, in Chapter 6of the Color Atlas/Text of Excimer Laser Surgery, © 1993 Igaku-ShoinMedical Publishers, Inc. These transition zones 124 and 126 reduce anysharp edges 122 from being created, which could otherwise result inundesirable patterns of epithelia regrowth, and also reduce ultimatedepth of ablation along the axis of treatment 102.

The following are two typical tables showing transition zones. Fortreatment to correct -9.00 diopters of myopia over a 5 mm treatment zone100, the following transition zones could be used:

    ______________________________________                                                     Min.  Max. Correction                                            No.          [mm] [mm]  [diopters]                                            ______________________________________                                        1            0.50-4.00  -9.00                                                 2            4.00-4.20  -7.50                                                 3            4.20-4.40  -6.00                                                 4            4.40-4.60  -4.50                                                 5            4.60-4.80  -3.00                                                 6            4.80-5.00  -1.50                                                 ______________________________________                                    

Using this table, first a standard myopic correction using the equationdiscussed below would be performed for the desired -9.00 diopters ofcorrection, but instead over a treatment zone 4.00 mm wide. Thisprovides full correction in the middle 4.00 mm zone. Then, a transitionis created by ablating from 4.00 to 4.20 mm using the lesser correctionof -7.50 diopters. This is repeated for the subsequent entries in thetable, thus forming transition zones of a greater radius of curvature.

Without the transition zones, 88 μm would be ablated at the axis oftreatment 102; with the transition zones, only 71 μm is ablated--20%less. This is good for the stability of the cornea.

An example of treatment for -12.00 diopters over a full 7 mm treatmentzone 100 is illustrated below:

    ______________________________________                                                     Min.  Max. Correction                                            No.          [mm] [mm]  [diopters]                                            ______________________________________                                         1           0.50-2.00  -12.00                                                 2           2.00-2.20  -11.54                                                 3           2.20-2.40  -11.08                                                 4           2.40-2.60  -10.62                                                 5           2.60-2.80  -10.15                                                 6           2.80-3.00  -9.69                                                  7           3.00-3.20  -9.23                                                  8           3.20-3.40  -8.77                                                  9           3.40-3.60  -8.31                                                 10           3.60-3.80  -7.85                                                 11           3.80-4.00  -7.38                                                 12           4.00-4.20  -6.92                                                 13           4.20-4.40  -6.46                                                 14           4.40-4.60  -6.00                                                 15           4.60-4.80  -5.54                                                 16           4.80-5.00  -5.08                                                 17           5.00-5.20  -4.62                                                 18           5.20-5.40  -4.15                                                 19           5.40-5.60  -3.69                                                 20           5.60-5.80  -3.23                                                 21           5.80-6.00  -2.77                                                 22           6.00-6.20  -2.31                                                 23           6.20-6.40  -1.85                                                 24           6.40-6.60  -1.38                                                 25           6.60-6.80  -0.92                                                 26           6.80-7.00  -0.46                                                 ______________________________________                                    

FIGS. 3A and 3B show an ablation pattern corresponding to one of theablation rings 104 to 114 of FIG. 2A, but using the laser "dithering,"or "polishing," according to the invention. The term "dithering" is usedin the sense that small random or pseudo random fluctuations are addedto the beam 22 to "smooth" particular errors that would otherwise buildup. Assuming one of the ablation rings 104 to 114 of FIG. 2A includesfive shots at a particular spot size, FIGS. 3A and 3B show the effectachieved according to the method and apparatus of the invention. In FIG.3A, the axis of treatment 102 is shown, upon which shots in past systemshave been centered, as shown in FIG. 2A.

According to the invention, however, the centers of the five shots arerandomly distributed in a dithering zone 140 with the center axis ofeach shot being away from the axis of treatment 102. Five shots usingrandomly distributed centers 142 through 150 result in five individualexcimer laser ablation shots 152 through 160. The radius of thedithering zone 140 is preferably somewhat less than the radius of theshots themselves. As can be seen, any reinforcement--i.e., ridge heightgreater than a single shot ridge height--occurs only incidentally, andgenerally the ridges are distributed over a dithering band 162. Thisprovides a "smoothing" effect, reducing average ridge height.

FIG. 3B shows an alternative manner of performing this polishing, inwhich the shot centers 142 through 150 are evenly distributed around theperiphery of the dithering zone 140. This case insures that none of theablation shots 152 through 160, even though of the same radius, formreinforcing ridges.

In this manner, a smoother surface of the eye 44 is achieved duringablation to correct for myopia. This polishing, or dithering, could alsobe described as an "oscillation" of the laser spot upon the cornea. Thisdithering could also be one dimensional rather than two, and could alsobe created by vibrating the patient's eye 44, such as by vibrating themask 52 or the patient himself. For example, a small mechanical vibratorcould be placed in a patient table or in the mask 52. This could thenprovide the oscillation necessary. As can be readily appreciated, such adithering technique can be applied to other forms of correction, such asusing ring apertures and slit apertures to correct for hyperopia andastigmatism, as are known in the art. Further, the dithering could beapplied to any other shot patterns such as for hyperopia andastigmatism, thus reducing the effects of both ridge height and beam 22inhomogeneity.

FIGS. 4A and 4B illustrate a large beam scanning pattern used to correctfor astigmatism according to the system and method of the invention. Inthe prior art, variable size slits were generally used to perform thiscorrection, requiring further hardware and generally inflexible patternsof correction.

The method and apparatus according to the invention, however, correctastigmatism within the treatment zone 100, here with width S and lengthL, through a series of lines 170 and 172 created by a series ofoverlapping shots in the area to corrected for astigmatism. In thediagram, only the first line 170 and the second line 172 are shown, withthe first line created using smaller spot sizes than the second line172. According to the method of the invention, a lesser or greaternumber of lines are used to provide the desired degree of correction forastigmatism. This results in the ablation profile as shown in FIG. 4B.This profile generally corresponds to the curvature needed for a myopiaablation, whose formula is discussed below in conjunction with FIG. 7A.

A typical pattern used for ablating to correct for astigmatism for a-2.00 diopter correction would involve shots of:

    ______________________________________                                        No.            Spot Size                                                                              Shots                                                 ______________________________________                                        1              1.067    11                                                    2              1.679    8                                                     3              2.141    7                                                     4              2.484    7                                                     5              2.726    6                                                     6              2.885    6                                                     7              2.977    6                                                     8              3.019    6                                                     9              3.022    6                                                     10             3.000    6                                                     ______________________________________                                    

At each spot size, a line is created corresponding to the lines 102 and104, and preferably the spots overlap by approximately 88%. This wouldcreate an appropriate modified curvature corresponding to a -2.00diopter correction for astigmatism. These would be spread over a 3 mmwidth S of the treatment zone 100.

FIG. 5 is an illustration of shot patterns used to correct fornon-symmetrical astigmatism. In this case, only a single treatment line174 is shown; typically, a greater number of lines would be used, butfor clarity, the single line 174 illustrates the treatment of a curvedastigmatism that does not extend linearly across an axis of treatment102 of the eye 44. In this way, a greater variety of types ofastigmatism are correctable.

FIG. 6A illustrates the large beam scanning according to the inventionused to correct for hyperopia without using ring apertures. Instead,only the single diaphragm 36 is used to adjust the spot size, and acircular ablation ring 180 over the treatment zone 100, as is well knownto those skilled in performing hyperopic ablation, is created usingmultiple rings of different spot sizes and various overlaps. Theapproximate ablation profile is shown in FIG. 6B. The formula for thecurvature for hyperopic ablation is discussed below in conjunction withFIG. 7B.

It will be noted that the shots for hyperopic ablation extend beyond thezone of treatment 100 of width S. The shots outside of this area do notprovide for optical correction, but instead provide a smooth transitionat the edge of hyperopic ablation. Further, although the circularablation ring 180 is not shown extending all the way to the center ofthe axis of treatment 102, the final series of shots at the largest shotsize preferably extend very close to that axis, to provide a smoothprofile from the center of the axis of treatment 102 to the edge of thetreatment zone 100.

A typical shot pattern for hyperopic correction of 5.00 diopters wouldinvolve shots of:

    ______________________________________                                        No.     Spot Size      Shots      Overlap                                     ______________________________________                                        1       2.000          1052       99.25 [%]                                   2       2.469          128        95                                          3       3.060          104        95                                          4       3.966           80        95                                          5       4.600           27        87                                          ______________________________________                                    

In this pattern, each series of shots is used to create a ring withcenters at a radius of 2.5 mm from the axis of treatment 102 of the eye44. In this case, the preferred overlap is variable per treatment ring,and is illustrated in the table.

As can further be appreciated, although the illustrated shot patternsuse circular apertures, another aperture shape could be used to createthe hyperopic correction pattern and the astigmatism correction patternaccording to the invention. For example, an oval shot shape could beused, and that oval could be rotated during the hyperopic correction,such that one axis of the oval pointed to the axis of treatment 102 ofthe eye 44. Alternatively, the oval could be rotated asynchronously withthe rotation about the axis of treatment 102, thus further reducing theeffects of inhomogeneity of the beam 22.

FIGS. 7A and 7B illustrate various mathematical attributes of theablation profiles of the preceding ablation patterns. FIG. 7A shows atypical ablation profile for myopic ablation and FIG. 7B illustrates atypical ablation profile for hyperopic ablation. In both, the initialradius of the cornea of the eye 44 is given by R_(OLD) and the new,desired radius of the cornea of the eye 44 is given by R_(NEW). Theabsolute zone of treatment 100 is designated of a width S, whichcorresponds to the effective area that performs the corrective function.It is typically between 2 and 8 mm, but can be larger or smaller. Thedepth of ablation at any point within the treatment zone 100 of width Sis given by a variable A, which stands for ablation depth. The distancefrom the axis of treatment 102 is given by a variable ρ.

To calculate the new radius R_(NEW), the old radius R_(OLD) and adesired dioptric correction D_(CORR) is used in the following equation:##EQU1##

NEW₋₋ RADIUS returns a parameter indicating the new radius of correctionneeded, R_(NEW), to given R_(OLD) and D_(CORR). Both R_(OLD) and R_(NEW)are measured in meters, and are typically between 5 and 15 mm.

The formula for calculating the necessary depth of ablation to correctfor myopia as illustrated in FIG. 7A is given below: ##EQU2## The myopicablation function MYO₋₋ ABLATE returns a needed depth of ablation at aparticular distance ρ from the axis of treatment 102, given theuncorrected radius of curvature of the eye 44 R_(OLD), a desired zone ofcorrection S, and a desired degree of correction D_(CORR). The functionMYO₋₋ ABLATE also provides the appropriate degree of correction acrossthe width S of a trench used to correct for astigmatism, as illustratedin FIGS. 4A and 4B.

Turning to FIG. 7B, the formula for hyperopic ablation is given below:##EQU3## The hyperopia ablate function HYP₋₋ ABLATE only uses threeparameters, as it does not need optical zone of correction S.

These specific algorithms for creating appropriate curvatures are wellknown in the art and can be found in MUNNERLYN, C. AND KOONS, S.,PHOTOREFRACTIVE KERATECTOMY: A TECHNIQUE FOR LASER REFRACTIVE SURGERY,Cataract Refract Surg., Vol. 14, (Jan. 1988).

Further, in the routines for performing ablation discussed below inconjunction with FIGS. 9-14, the inverse of these equations are needed.While the above equations return a depth of ablation needed at aparticular value of ρ for a given degree of correction, the inverseequations do the exact opposite. They return the particular value of ρat which a particular depth of ablation is needed given a particulardegree of correction. These equations are given below: ##EQU4##

The inverse myopic ablation function INV₋₋ MYO₋₋ ABLATE returns aparameter indicating the distance corresponding to ρ from the center ofablation in meters given a depth of ablation A, also in meters. It alsouses the parameters R_(OLD), S, and D_(CORR).

The inverse hyperopic ablation function INV₋₋ HYP₋₋ ABLATE also returnsa radius from the center of ablation in meters corresponding to ρ, givena depth of ablation A at a certain correction D_(CORR) It returns ρindicating how far away from the center of ablation a certain depth ofablation will be found.

FIG. 8 illustrates how the system using aiming of the axis of ablationand variable spot sizes can correct for any topography of the eye 44that is abnormal, including non-symmetric topographies. In FIG. 8, oneline of a desired treatment topography 190 is illustrated. This could beretrieved, for example, from a computerized eye topography system whichindicates various abnormalities in the surface of the eye 44. Using sucha topography system, the eye surgery system 10, using the control unit64, then performs a series of shots, which, for simplicity, areillustrated as eight shots 192 through 206. In actual practice, a fargreater number of shots would likely be used. As the system knows theneeded ablation at each point, it creates a map of the topographydesired and performs ablation using various shot sizes aimed at variouspoints to perform the necessary correction. In this way, a wide varietyof non-symmetrical defects of the cornea can be corrected, such as appleand banana shapes, as well as any other abnormal shape.

FIG. 9 is a flowchart illustrating a CALCULATE routine 700 that wouldexecute preferably on the control unit 64. The CALCULATE routine 700calculates a series of shot patterns necessary to perform the desiredablation of the eye 44 to correct for a variety of conditions. In thedescribed embodiment, shot patterns are created to correct forastigmatism, hyperopia, and myopia as described in conjunction withpreceding FIGS. 2A to 7. Further, the dithering as illustrated in FIGS.3 and 4 is applied to myopic correction shot patterns.

Preferably, the CALCULATE routine 700 runs in the control unit 64, whichperforms the necessary shot calculations before beginning an ablationsequence. By having all the points precalculated, there is no delay incalculation, so each successive shot can be fired in rapid sequence, assoon as the excimer laser 20 is ready. This provides for quickertreatment times and less difficulty in having the patient center on anoptical fixation point.

Beginning at step 702, the CALCULATE routine 700 sets a variable START₋₋DITHER to 1. This variable indicates the first ablation shot at whichdithering is to begin, and is further discussed below. Note that all ofthe ablation shots are preferably stored in an array, and START₋₋ DITHERindicates a location within that array. Control proceeds from step 702to step 704, where the routine 700 determines whether astigmatismcorrection is desired. This is pre-entered by the physician, includingboth angle of and degree of astigmatic correction, along with themaximum treatment area. As is readily apparent, the routine 700 couldalso request a degree of curvature for the line of astigmatic correctionin the case of nonsymmetric astigmatism, and even provide for greatercorrection towards one or the other ends of the astigmatic region.

If astigmatic correction is desired, control proceeds from step 704 tostep 706, where an ASTIGMATISM routine 750 is performed (discussed belowin conjunction with FIGS. 10A and 10B), creating the appropriate shotpatterns for the desired astigmatic correction. These shot patterns, forexample, correspond to those discussed in conjunction with FIGS. 4A and4B.

Once the shot pattern for astigmatic correction is calculated at step706, control proceeds to step 708, where START₋₋ DITHER is set to avariable LAST₋₋ VECTOR. LAST₋₋ VECTOR points to the last calculated shotin the array for an ablation run. In this case, it points to the lastvector calculated by the ASTIGMATISM routine 750. Because astigmatisminvolves overlapping shots rather than potentially reinforcing shots,dithering is preferably not performed during astigmatism correction inthe disclosed embodiment, although it could be.

From step 704, if no correction for astigmatism was desired, and fromstep 708 in any case, control then proceeds to step 710, where theCALCULATE routine 700 determines whether correction for myopia isdesired. If not, correction for hyperopia is desired, so controlproceeds to step 712 where a HYPEROPIA routine 850 is performed, to bediscussed below in conjunction with FIG. 12. As correction for hyperopiais similar to correction for astigmatism, but with the shots in a circlerather than a line, dithering is preferably not performed (although itcould be) in the disclosed embodiment, so control then proceeds to step714, where the routine 700 returns to a master routine, which thenallows the physician to begin execution of the shot sequence calculatedby the CALCULATE routine 700.

If at step 710 it was determined that correction for myopia is desired,the CALCULATE routine 700 then proceeds to step 716, where it determineswhether transition zones are requested. If so, multiple myopic shotseries must be formed with the initial "transition zone" series beingcreated by performing a myopia correction. This was discussed above inconjunction with FIG. 2B. So, control proceeds to step 718 where aMYOPIA routine is performed to create a transition zone. This creates astandard myopia correction shot sequence for the transition zone.

Proceeding again to step 716, it is again determined whether moretransition zones are required. If the last transition zone shot sequencehas been calculated, or if none is needed, control then proceeds to step720, where the MYOPIA routine is again executed, this time to providethe final correction for myopia.

The creation of series of shot sequences to correct for myopia is wellknown in the art. Given the necessary depth of ablation as determined bythe MYO₋₋ ABLATE function described above, a shot pattern is createdusing appropriate shot sizes to conform to the necessary depth ofablation at each point radiating away from the axis of treatment 102.

Control then proceeds to step 722, where a DITHER routine 940 or 970 isexecuted as described below in conjunction with FIGS. 13 and 14,performing dithering, or randomizing, on all shots from START₋₋ DITHERas set in either step 702 or step 708 to LAST₋₋ VECTOR, which wasdescribed above in conjunction with step 708. At this point, calculationof the ablation shot sequence is complete, so control proceeds to step714 where the CALCULATE routine 700 returns to the main program so thatthe physician can execute the ablation run as is now stored in thearray.

FIGS. 10A and 10B are a flowchart of the ASTIGMATISM routine 750 that isused to calculate the shot vectors necessary to create "trenches" ofoverlapping lines to correct for a desired dioptric degree ofastigmatism along a particular axis. An appropriate number of trenchesare created, with each trench preferably using progressively larger spotsizes. Beginning at step 752, the necessary depth of overall ablation iscalculated at the deepest part of the series of trenches. This is doneusing the myopic ablation function MYO₋₋ ABLATE, described above inconjunction with FIG. 7A. A variable MAX₋₋ ABLATE is set to the valuereturned by MYO₋₋ ABLATE using ρ=0, indicating the necessary depth atthe center of the trench (the deepest point). Also passed to MYO₋₋ABLATE are the uncorrected radius of curvature R_(OLD), the necessarydioptric correction D_(CORR) and the width of the astigmatism treatmentzone S. Note that S is equal to the width of the astigmatism treatmentzone, not the length.

Control then proceeds to step 754, where the necessary depth of ablationper trench is calculated. This is preferably calculated as is MAX₋₋ABLATE above, but instead setting a variable ABLATE, which indicates theamount of ablation per trench, to a value equal to MAX₋₋ ABLATE dividedby 10. This indicates that preferably ten trenches are to be made,although less may be required as the amount of ablation per trench iscalculated.

Control then proceeds to step 756, where a variable DEPTH is set equalto the previously calculated MAX₋₋ ABLATE minus ABLATE. DEPTH indicatesthe amount of ablation remaining to be performed to provide the desireddegree of correction.

Control then proceeds to step 758, where a minimum spot diameter MIN₋₋SPOT₋₋ DIAM is calculated, indicating the smallest spot diameter to beused to create a trench. MIN₋₋ SPOT₋₋ DIAM is set equal to two times theradius returned by the inverted myopic ablation function INV₋₋ MYO₋₋ABLATE. INV₋₋ MYO₋₋ ABLATE is called with the initial radius ofcurvature R_(OLD) with A set to DEPTH plus ABLATE/2, with D_(CORR) asthe degree of dioptric correction desired, and with S as the width ofthe treatment zone. The value returned by calling this function is theradius at which 95% of the overall ablation depth needed will beperformed, and this radius will preferably be relatively close to thecenter of the axis of treatment--i.e., the radius will be small comparedto the overall width of each trench.

Proceeding to step 760, a maximum spot diameter MAX₋₋ SPOT₋₋ DIAM is setequal to S, which is simply the width of the astigmatism treatment zone100 (not the length).

Proceeding to step 762, a loop is entered that creates a series oftrenches to provide for the overall degree of correction for astigmatismneeded. First, at step 762 it is determined whether DEPTH is greaterthan zero. Again, DEPTH is the remaining depth necessary to ablate,which will be greater than zero when enough trenches have not beencreated to provide the desired degree of correction.

If DEPTH is greater than zero, control proceeds to step 764, where thespot diameter SPOT₋₋ DIAM is set equal to two times the result returnedby INV₋₋ MYO₋₋ ABLATE, when that function is called with A set equal toDEPTH. This returns the radius at which the ultimate necessary ablationequals DEPTH. As DEPTH is initially nearly equal to the overall depth ofablation needed, the initial spot diameter will thus be small.

Proceeding to step 766, the spot diameter SPOT₋₋ DIAM is empiricallycorrected. This is done by setting SPOT₋₋ DIAM equal to(1+(0.3·SIN(π·(SPOT₋₋ DIAM-MIN₋₋ SPOT₋₋ DIAM)/(MAX₋₋ SPOT₋₋ DIAM-MIN₋₋SPOT₋₋ DIAM)))). This performs an empirical adjustment to the spotdiameter to provide better results and better conform the overallcorrection to the desired curve necessary to correct for astigmatism.

Proceeding to step 768, a variable STEP indicating the amount to movethe spot target on each succeeding shot is set equal to SPOT₋₋DIAM·(DEPTH₋₋ PER₋₋ SHOT/ABLATE). DEPTH₋₋ PER₋₋ SHOT is the amount ofablation per shot, and is typically 0.2 μm. Then, at step 770 a variableOVERLAP is set equal to 100·(SPOT₋₋ DIAM-STEP)/SPOT₋₋ DIAM. This is theamount of overlap in percent needed for each shot.

Proceeding to step 772, a routine LINE 800 is called, discussed below inconjunction with FIG. 11, with Θ set to the angle at which to create theline of astigmatism, a LENGTH variable set to a predetermined length ofthe astigmatism series of shots plus 2·SPOT₋₋ DIAM, SPOT₋₋ DIAMindicating the spot size, and OVERLAP.

The series of shots for the line having been created, control proceedsto 774, where DEPTH is reduced by ABLATE, which is the amount to ablateper trench. Control then loops to step 762, where the reduced value ofDEPTH is again compared to zero. This loop is repeated, creating linesof shots with progressively larger spot diameters, until DEPTH is lessthan zero. DEPTH will be less than zero when virtually all of theablation shots have been calculated necessary to perform the desireddegree of correction.

Once DEPTH is less than zero, control proceeds to step 776, where it isdetermined whether DEPTH plus ABLATE is greater than DEPTH₋₋ PER₋₋ SHOT.If not, then another line of ablation should not be performed, as thatwould provide too much correction, so control then proceeds to step 778where the ASTIGMATISM routine 750 returns to the CORRECTION routine 700.

If at step 776 the "residue" of ablation still needed does not exceedDEPTH₋₋ PER₋₋ SHOT, control instead proceeds to step 780. There, SPOT₋₋DIAM is set to the maximum spot diameter of S, which is the width of thetreatment zone 100 for the astigmatism line of trenches, STEP is setequal to SPOT₋₋ DIAM·DEPTH₋₋ PER₋₋ SHOT/(ABLATE+DEPTH) and OVERLAP isset equal to (SPOT₋₋ DIAM-STEP)·100/SPOT₋₋ DIAM.

Control then proceeds to step 782, where a final trench is created usingthe variables set at step 780 spot width by calling the routine LINE800. The routine 750 then returns at step 778.

The ASTIGMATISM routine 750 thus creates a shot pattern as describedabove in conjunction with FIG. 4A.

FIG. 11 is a flowchart of the LINE routine 800. This routine 800calculates the shots for the generation of a line used in creating anastigmatism correction sequence of shots. The desired spot size ispassed to the routine 800 in a variable SPOT₋₋ DIAM, an overlappercentage is passed in a variable OVERLAP, and the length of the lineis determined by a LENGTH variable passed to the LINE routine 800.

Beginning at step 802, the LINE routine 800 first calculates the stepsize, which is equal to SPOT₋₋ DIAM·(1-OVERLAP). Proceeding to step 804,the number of shots required is calculated equal to the truncated valueof (LENGTH-SPOT₋₋ DIAM+STEP)/STEP. Proceeding to step 806, a countervariable I is set equal to a variable START₋₋ VECTOR which is equal toLAST₋₋ VECTOR+1. LAST₋₋ VECTOR is set equal to I upon completion of theLINE routine 800.

Control then proceeds to step 808, where a variable corresponding to theX axis displacement from the axis of treatment 102 is set equal to((LENGTH-SPOT₋₋ DIAM)/2) ·cos θ, where θ is the angle of desiredastigmatic correction. In step 810, Y is correspondingly set to((LENGTH-SPOT₋₋ DIAM)/2)·sin θ.

Control then proceeds to step 812, where it is determined whether Iequals START₋₋ VECTOR plus SHOTS, indicating the end of this line ofshots. If not, control proceeds to step 814, where an array location X₋₋SHOT[I] corresponding to the shot location of this particular shot isset equal to X and Y₋₋ SHOT[I] is correspondingly set equal to I. Then,at step 816 X is set equal to X+(STEP·cos θ) and Y is set equal toY+(STEP·sin θ). This is the delta increment required for the next shot.

Control then proceeds to step 818, where I is incremented, and theroutine then loops to step 812. Once I is equal to START₋₋ VECTOR+SHOTS,indicating the end of this line, the routine returns to the ASTIGMATISMroutine 750 at step 814.

FIG. 12 is a flowchart of the HYPEROPIA routine 850 that createscircular trenches about the axis of treatment 102. It is similar to theASTIGMATISM routine 750, but creates the circular trenches of anappropriate profile to correct for hyperopia rather than for astigmatism(which uses a myopia correction function).

Beginning at step 852, a variable DEPTH is set equal to the parameterreturned by HYP₋₋ ABLATE discussed above in conjunction with FIG. 7B,when ρ is set equal to S/2-MIN₋₋ SPOT₋₋ RADIUS, where S is the diameterof the appropriate area of treatment and MIN₋₋ SPOT₋₋ RADIUS is theminimum spot size to ever be used for hyperopia ablation, which could beset, for example to 200 μm. HYP₋₋ ABLATE is also called with R_(OLD)representing the uncorrected curvature of the eye 44 and D_(CORR)representing the desired degree of dioptric correction. DEPTH thusequals the remaining depth to ablate. It is initially less than thetotal depth to ablate, as ρ was set just inside the circle of ablationas indicated by S/2 with MIN₋₋ SPOT₋₋ RADIUS subtracted, which is thefirst spot radius at which to ablate.

Proceeding to step 854, a variable ABLATE, which indicates the amount toablate for this hyperopia treatment, is set equal to a parameterreturned by HYP₋₋ ABLATE called with ρ equal to S/2, with that returnedparameter decreased by the amount DEPTH. Thus, ABLATE is the differencein depth at the edge of the area of treatment as indicated by S/2 andthe depth at a distance MIN₋₋ SPOT₋₋ RADIUS just inside that treatmentarea.

Proceeding to step 856, a variable SPOT₋₋ DIAM is set equal to MIN₋₋SPOT₋₋ RADIUS·2, a variable STEP is set equal to SPOT₋₋ DIAM·DEPTH₋₋PER₋₋ SHOT/ABLATE, and a variable OVERLAP is set equal to ((SPOT₋₋DIAM-STEP)/SPOT₋₋ DIAM)·100 (i.e., expressed as percent). Thus, thefirst circular trench will be shot using the minimum spot diameter asindicated by MIN₋₋ SPOT₋₋ RADIUS·2.

Proceeding to step 858, a routine CIRCLE₋₋ LINE is called whichcalculates the series of shots necessary to ablate a circular trenchgiven the variables SPOT₋₋ DIAM, STEP, and OVERLAP. The CIRCLE₋₋ LINEroutine directly corresponds to the LINE routine 800, except that thecircle is shot at a fixed radius given by S/2, instead of being shotalong a line. Its implementation corresponds to the LINE routine 800,with the exception that each succeeding shot is incremented along theradius of ρ equal to S/2, rather than along a line.

Proceeding to step 860, ABLATE is set equal to a parameter returned byHYP₋₋ ABLATE when HYP₋₋ ABLATE is called with ρ equal to S/2, with thatreturned parameter then divided by 10. This corresponds to preferablyten trenches being ablated to form the appropriate profile of curvatureto correct for hyperopia.

Proceeding to 862, DEPTH is then set to DEPTH minus ABLATE, whichreduces DEPTH by 1/10th of the total depth needed to ablate thehyperopic trench.

The routine 850 then proceeds to step 864, where it is determinedwhether DEPTH, which indicates the total depth remaining to ablate, isgreater than zero. If so, then there remaining trenches to ablate, sothe routine proceeds to step 866, where SPOT₋₋ DIAM is set equal to theparameter returned by INV₋₋ HYP₋₋ ABLATE when that function is calledwith A equal to DEPTH. This then returns the radius at which ablationmust occur to a depth equal to the current value of DEPTH in order toprovide the appropriate correction for hyperopia. This returnedparameter, however, is a radius from the axis of treatment 102. Tocalculate the actual spot diameter, SPOT₋₋ DIAM is set equal to2·(S/2-SPOT₋₋ DIAM). This sets SPOT₋₋ DIAM to two times the differenceof the radius of the actual zone of treatment minus the radius at whichthe current ablation depth is to occur. This difference in radii timestwo is thus equal to the spot diameter for the current trench to ablate.

Proceeding to step 868, STEP is set equal to SPOT₋₋ DIAM·DEPTH₋₋ PER₋₋SHOT/ABLATE. Proceeding to step 870, OVERLAP is set equal to ((SPOT₋₋DIAM-STEP)/SPOT₋₋ DIAM)·100, which sets the appropriate overlap inpercent.

Using these values of SPOT₋₋ DIAM and OVERLAP, and with ρ equal to S/2,at step 872 the routine CIRCLE₋₋ LINE is called, creating a circulartrench. Proceeding to step 874, DEPTH is again set equal to DEPTH minusABLATE. The routine then loops to step 864, and continually loopsthrough steps 866 through 874 until DEPTH is not greater than zero.

When DEPTH is not greater than zero at step 864, the routine 850proceeds to step 876, where it is determined whether ABLATE plus DEPTHis greater than RESIDUE, where RESIDUE is an arbitrary value at whichanother trench is not to be ablated. This value is preferably 500microns, although could be a different value. If ABLATE plus DEPTH isgreater than RESIDUE, then more than that RESIDUE value remains to beablated, so the routine 850 proceeds to step 878, where a final trenchis created using a SPOT₋₋ DIAM of 2·(S/2-MIN₋₋ SPOT₋₋ SIZE) and anOVERLAP of ((SPOT₋₋ DIAM-STEP)/SPOT₋₋ DIAM)·100. Then from step 876 andstep 878, the routine returns at step 880.

FIG. 13 is a flowchart of a RAND₋₋ DITHER routine 940 which correspondsto the DITHER routine as noted in step 722 of FIG. 9. The RAND₋₋ DITHERroutine 940 randomly dithers all vectors in the described array fromSTART₋₋ DITH to LAST₋₋ VECTOR. START₋₋ DITH was previously set at step702 or step 708 of FIG. 9 to be equal to the first array locationfollowing shots used for correction of astigmatism. Thus, dithering ispreferably applied to the myopia correction, rather than to theastigmatism correction. The RAND₋₋ DITH routine 970 creates a shotpattern as is illustrated in FIG. 3A.

The RAND₋₋ DITHER routine 940 begins at step 942 by setting a countervariable I to START₋₋ DITH. Control then proceeds to step 944, where anintermediate variable X₋₋ DUM is set equal to a random number RANDOMbetween -0.5 and 0.5 times AMPLITUDE times SPOT₋₋ SIZE[I]. The variableAMPLITUDE was passed to the RAND₋₋ DITHER routine 940 as indicating theappropriate amplitude of dithering in fractional percentage of spotsize, and SPOT₋₋ SIZE[I] corresponds to the spot size for thisparticular shot.

Control then proceeds to step 946, where the routine 940 determineswhether the absolute value of X₋₋ DUM is greater than a limiting sizedenoted by a variable LIMIT, which is predetermined by the system. IfX₋₋ DUM is too large, control then proceeds to step 948, where X₋₋ DUMis set equal to LIMIT X₋₋ DUM/ABS(X₋₋ DUM), which sets X₋₋ DUM to LIMITwith the appropriate sign appended.

If X₋₋ DUM was not too large in step 946, and in any case from step 948,control then proceeds to step 950, where X₋₋ SHOT[I] is set equal to X₋₋SHOT[I]+X₋₋ DUM, which provides a random dithering effect according tothe invention. Control then proceeds to steps 952, 954, 956, and 958,where Y₋₋ SHOT[I] is adjusted with the random dithering as X₋₋ SHOT[I]was dithered at steps 944 through 950.

Control then proceeds from step 958 to step 960, where the RAND₋₋ DITHERroutine 940 determines if I=LAST₋₋ VECTOR, indicating that the lastvector desired has been dithered. If not, control proceeds to step 962,where I is incremented, and control then loops to step 944 to processthe next shot.

If at step 960 I equals LAST₋₋ VECTOR, the RAND₋₋ DITHER routine 940 iscomplete, so the routine 940 then returns at step 964.

FIG. 14 shows an alternative routine CIRCLE₋₋ DITH 970, which can beused instead of the RAND₋₋ DITH routine 940. A shot pattern as createdby the CIRCLE₋₋ DITH routine 970 is illustrated in FIG. 3B. The CIRCLE₋₋DITH routine 970 begins at step 972, where a variable NUM₋₋ VECT is setLAST₋₋ VECTOR-START₋₋ VECTOR, both of which were passed by the callingroutine. Proceeding to step 974, it is determined whether NUM₋₋VECT/ROTATIONS is less than 10. The variable ROTATIONS is passed to theroutine 970 to indicate how many circular rotations to make around theaxis of treatment 102 in adjusting all of the shots. The check is madeat 974 to prevent an excessive number of rotations if there areinsufficient shots. For example, if there are only twenty vectors, tenrevolutions would result in two sets of ten shots each 180° apart. Byarbitrarily requiring NUM₋₋ VECT/ROTATIONS to be at least 10, thisprevents such accumulation of shots, requiring the shots be distributedover at least ten different points around the axis of treatment 102. IfNUM₋₋ VECT/ROTATIONS is less than 10, control proceeds to step 976,where ROTATIONS is set equal to the truncated value of NUM₋₋ VECT/10.From step 976 and 974, if that step was not true, control then proceedsto step 978, where I is set equal to START₋₋ VECTOR.

Control then proceeds to step 980, where X₋₋ SHOT[I] is set equal to X₋₋SHOT[I]+(DIAM/2)·cos ((2π·I·ROTATIONS)/NUM₋₋ VECT). This circularlyadjusts the center of each shot. Y₋₋ SHOT[I] is correspondingly adjustedin step 982.

From step 982, control proceeds to step 984, where it is determinedwhether I is equal to LAST₋₋ VECTOR. If not, control then proceeds tostep 986 where I is incremented for another pass through steps 980 and982 to adjust subsequent vectors.

If from step 984 I is equal to LAST₋₋ VECTOR, control then proceeds tostep 988, where control returns to the CALCULATE routine 700.

It will be readily appreciated that this dithering, or oscillation,could also be applied one dimensionally, and could be used for hyperopiaand astigmatism correction as well.

FIG. 15 illustrates an image returned by the video unit 56 in performingepithelia ablation using infrared dye and using the scanning large beamaccording to the invention. The epithelium is typically approximately 50μm thick. As the preferred excimer laser 20 used in the system Saccording to the invention ablates approximately 0.2 μm per shot, 250initial shots will typically be needed until the epithelium has beenablated. At some time before that point, however, variations of theepithelia thickness come into play. For example, some points might be 40μm thick, while others are 60 μm thick.

The system S according to the invention removes the epithelium bysensing when it has completely removed at least a portion of theepithelium, and then selectively removing the remainder. FIG. 15illustrates an epithelial removal zone 1000 in which a predeterminednumber of shots have been previously performed using a spot size thesize of the epithelial removal region 1000. After each shot, theinfrared video unit 56 captures any infrared fluorescence emitted fromthe eye 44. This fluorescence is created by first dyeing the epitheliumwith an infrared fluorescent dye that does not dye the layers underlyingthe epithelium. This dye is preferably infrared fluorescent to reducethe possibility of a pumped lasing action into the eye 44 of damagingfrequencies of light at damaging energies. Other dyes could be used,including visible light emitting dyes, if it is ensured that no pumpedlasing action will occur that might damage the eye 44. Infraredfluorescent dye is also preferred to prevent any distracting opticalaffects to the patient while the epithelium is being ablated.

After a predetermined number of shots, the video unit 56 will detectsome portion of the epithelial removal region 1000 that does notfluoresce. This indicates that there is no infrared fluorescent dye atthat location, which correspondingly indicates the epithelium has beenentirely ablated at that point.

In FIG. 15, two regions 1002 and 1004 are shown in which all of theepithelium has been removed by the predetermined number of shots. Atthis point, the spot size is reduced, and a region 1006 in which theepithelium still remains, as indicated by the infrared fluorescent dye,is further ablated.

Either under computer control or under physician control, the selectiveablation is performed as illustrated in FIG. 16. In FIG. 16, theremaining region 1006 has been further ablated using reduced spot sizes,forming further epithelial free regions 1008, 1010, 1012, 1014, and1016. The video unit 56 further observes the epithelial removal region1000 during ablation of each of these remaining regions, detecting whena certain portion of those regions do not fluoresce. Again, differencesin epithelial depth across each of these regions can result in onlypartial ablation of the epithelium in these remaining regions. Forexample, an island 1018 of epithelium is shown remaining in the region1008 which has been further ablated. Such islands must be furtherablated, along with any remaining portion of the epithelium 1006 whichhas not been removed by the subsequent ablation.

It will be recognized that by keeping a computer map of the epithelialremoval region 1000, along with the number of shots fired onto eachparticular point in that region, a map of epithelial thickness can becreated. By knowing the ablation depth of each shot, along with whereeach shot has been fired, it is known how many shots a particular pointreceives before all of the epithelium is removed from that region. Thus,a map of the thickness of the epithelium is created. This map would besimilar to that created in correcting for non-symmetrical opticalaberrations as discussed in conjunction with FIG. 8.

It will be appreciated that the large beam scanning and ditheringaccording to the invention need not only be applied to the surface ofthe eye 44. For example, U.S. Pat. No. 4,903,695, entitled "Method andApparatus for Performing a Keratomileusis or the Like Operation," issuedFeb. 27, 1990, discloses a method of removing a portion of the corneafrom the eye and then ablating the exposed surface. Thus, the method andapparatus according to the invention can also be used on the exposedsurface resulting from such a Keratomileusis type procedure. In such acase, the axis of treatment 102 would fall either on either the severedportion of the cornea or on the surface of the cornea from which aportion had been severed.

FIG. 17 is perspective view of a lens ablation pattern 1100 according tothe invention for correcting for myopia. FIG. 17 illustrates inperspective greater ablation depth corresponding to the height of theperspective drawing. The lens ablation pattern 1100 is created bycreating two standard astigmatism ablation patterns 1104 and 1106 (i.e.,"cylindrical lenses") as illustrated and discussed in conjunction withFIGS. 4A, 4B, 10A, 10B, and 11. These two standard astigmatism ablationpatterns 1104 and 1106 are preferably created at right angles to oneanother.

The lens ablation pattern 1100 includes a central region 1102 where thetwo standard astigmatism ablation patterns 1104 and 1106 intersect. Thecentral region 1102 preferably encompasses the optically active area ofthe treatment zone, while the arms of the standard astigmatism ablationpatterns 1104 and 1106 extend outward from that treatment zone.

FIG. 18A is a top view of the perspective view of FIG. 17. As can beseen, the central region 1102 encompasses an optically active area 1200of the treatment zone. It is preferable that the optically active area1200 resides within the central region 1102 where the two standardastigmatism ablation patterns 1104 and 1106 intersect, but that is notabsolutely necessary, as a small portion of the central region 1102could extend into the separate arms of the standard astigmatism ablationpatterns 1104 and 1106.

FIG. 18A also shows a transition zone 1202, which would correspond toextra ablation on the sides of each of the standard astigmatism ablationpatterns 1104 and 1106 to provide a smooth transition zone, preventingridges, as discussed above in conjunction with FIGS. 2B and 9.

FIGS. 18B and 18C show end-on views of each of the standard astigmatismablation patterns 1104 and 1106, along with the central region 1102.

When two standard astigmatism ablation patterns 1104 and 1106 arecreated at right angles, the central region 1102 results in a lens withthe focusing properties of the standard spherical lens used to correctmyopia. For example, if two -2.00 diopter standard astigmatism ablationpatterns 1104 and 1106 are ablated at right angles, the resultingcentral region will be a -2.00 diopter myopia correcting lens.

It is believed that by creating the cylindrical lens in the centralregion 1102 through the two standard astigmatism ablation patterns 1104and 1106, central islands can be minimized. In any case, use of the twostandard astigmatism ablation patterns 1104 and 1106 to create a lenswith spherical lens properties further increases the advantages oflarge-beam scanning dithering, as described above in conjunction withFIGS. 3A, 3B, 4A, and 4B.

Further, astigmatism can also be treated by providing a lower dioptercorrection for one of the standard astigmatism ablation patterns 1104 or1106 than the other. For example, use of -1.00 diopter correction at 90°and -2.00 diopter correction at 0° will result in -1.00 diopter ofmyopia correction with an additional -1.00 diopter of astigmatismcorrection at 0°.

Ablation of the cylindrical lenses that form the standard astigmatismablation patterns 1104 and 1106 at angles other than 90° to one anotheralso creates a lens that corrects for myopia while simultaneouslyproviding further correction for astigmatism. For example, a -2.00diopter correction at 0° in conjunction with a -2.00 diopter correctionat 45° results in a -0.59 diopter correction for myopia with a further-2.83 diopter correction for astigmatism at 22.5°. Similarly, a -2.00diopter correction at 0° in conjunction with a -2.00 diopter correctionat 10° results in a -0.03 diopter correction for myopia in conjunctionwith a -3.94 diopter correction for astigmatism at 5°. These arecalculated using standard formulas based on adding lenses, as are knownto the art.

It will be appreciated that whatever the method used to create thestandard astigmatism ablation patterns 1104 or 1106, whether large-beamscanning or the various types of apertures disclosed in the background,such as a variable-width slit aperture of rectangular shape, theresulting central region 1102 will have the appropriate properties fortreating myopia. Whatever the method or technique used for creating thecylindrical lenses, the intersecting cylindrical lenses form anappropriate corrective pattern.

By reversing the process, that is by creating the inverse of thestandard astigmatism ablation patterns 1104 and 1106 using the varioustechniques described, or other known techniques, hyperopia can likewisebe corrected. This would be achieved by using standard astigmatismablation patterns 1104 and 1106 of positive diopter.

Turning now to FIGS. 19 through 24, these Figures illustrate the centerpoints of shot patterns calculated by a ring searching algorithm furtherdiscussed below in conjunction with FIG. 27 and a dither shot patternalgorithm further discussed below in conjunction with FIG. 28. Theseprograms generate a number of shot patterns with center locations awayfrom the center point of the treatment area, and also using fixed spotsizes according to the invention. It will be appreciated that a large,fixed spot size is used with center locations of shots as far as 2.5 mmfrom the center of the treatment zone. It will also be appreciated thatby using a large spot size, the greatest area of tissue is ablated pershot, requiring fewer shots. It will further be appreciated that theridging effects that are reduced by using the dithering according to theinvention discussed earlier in conjunction with FIGS. 3A and 3B, is evenfurther eliminated by the searching and shot dithering according to theinvention, as these shot patterns produce virtually no reinforcingridges. The programs illustrated by the flowcharts of FIGS. 27 and 28are attached as Appendices A, B, and C. The program of FIG. 27 andattached Appendix A generates shot patterns by empirically determining aseries of rings containing shots that will satisfy a desired ablationpattern. The program attached as Appendix B and illustrated in FIG. 28distributes fixed sized shots over the treatment area using a shotdithering pattern, with a variety of different shot dithering patternsavailable. Further, the program attached as Appendix C and illustratedin FIG. 28 provides for either randomly sorting the resulting shotpatterns or sorting the shot patterns with maximum displacement betweensequential shots. Further, by displacing subsequent shots from eachother, rather than having a particular point in the shot pattern alwaysbeing ablated, and rather than having each subsequent shot overlap animmediately previous shot, thermal heating is reduced, allowing forgreater shot rates.

FIGS. 19 through 25 illustrate various shot patterns produced by theprograms illustrated in FIGS. 27 and 28. FIGS. 19 and 20 illustrate shotpatterns created using the shot dithering (as opposed to thedisplacement dithering of FIGS. 3A and 3B) illustrated by the flowchartof FIG. 28. FIGS. 21-23 illustrate shot patterns created by the searchalgorithm illustrated in FIG. 27. FIG. 19 was created using a constant2.00 mm spot size to correct to -5.00 diopters. FIG. 20 was similarlycreated for a 2.00 mm spot size for correction to -5.00 diopters, butusing a modified spiral pattern according to the invention and describedin FIG. 28.

FIG. 21 was created for a 4.25 mm spot size to correct to -5.00 dioptersusing the ring searching according to the invention, while FIG. 22 wascreated for a 2.00 mm spot size to correct to -7.00 diopters using thering searching according to the invention. FIG. 23 was created using thering searching algorithm according to the invention to correct forhyperopia, created for a 2.00 mm spot size at +5.00 diopters ofcorrection.

FIGS. 24A, 24B and 24C are a list of shots used to create the treatmentpattern of FIG. 21, further illustrating the output of the ringsearching algorithm according to the invention. As can be seen, thereare no overlapping shots, and the shots in the sequence have beenordered by their X displacement in microns.

Turning to FIG. 25, the general steps of how the shot pattern is createdby the searching algorithm of FIG. 27. In FIG. 25, it is seen that anumber of concentric rings are determined by the search algorithmdiscussed below in conjunction with FIG. 27. Concentric rings 1500 to1510 are determined using the program attached as Appendix A. Then, foreach ring, the appropriate number of shots is determined. Taking ring1500 for example, the number of shots needed and their spacing aroundthe ring are calculated in order to correct to the appropriate degreewithin a particular treatment zone 1512. Then, appropriate shots arecalculated for the ring 1502 and so on. In this way, the patterns ofFIGS. 21 through 23 are calculated.

Referring to FIG. 26, it is seen that the ring that is determinedincludes a number of relatively large shots 1520 to 1530, preferablyaround 2.0 to 3.5 mm, that overlap around the ring 1500. The maximumshot rate that the tissue on one point of the cornea can typicallyabsorb is 40 shots per second at 0.25 micron per shot of ablation. Toincrease this rate according to the invention, an alternating pattern isadopted. Other techniques are also described in conjunction with FIG.27, but the basic concept is shown here. Rather than repeatedly fire ata particular point that might result in the 40 shot per second ratebeing exceeded, alternating shots are fired on opposite sides of thering, for example. Referring to FIG. 27, an actual shot pattern used isshown. As is seen, the first shot 1520 is fired on the bottom of thepattern, then the second shot 1522 then is fired on the top of thepattern adjacent to, but not overlapping, the first shot 1520, the thirdshot 1522 is fired on the bottom of the pattern overlapping the firstshot 1520. Further, overlapping patterns can then be fired, again usingthis alternating technique. The point behind this technique is to createthe series of overlapping shots of FIGS. 25 and 26 without eachsubsequent shot actually overlapping the previous shot fired. Furtheraccording to the invention, each particular spot, shot 1520, forexample, generally is a series of shots. But rather than fire a seriesof shots in succession, the entire ring can be created using singlealternating shots as illustrated in FIG. 26, but repeating the patterncreated by this series of single alternating shots of FIG. 26 as isneeded for the particular ring 1500. In this way, instead of completingthe ablation at one particular point, the ablation is distributed, andhigher shot rates can be realized. It will be understood that when shotsare needed close to the center of the pattern, as is illustrated by thering 1510 in FIG. 25, it may not be possible to prevent a single pointfrom being continuously ablated by displacing these shots. In such acase, it would be desirable to slow down the shot rate.

Turning to FIG. 27, the general flow of the program attached as AppendixA is shown. A routine SHOT₋₋ PATTERN 2000 empirically calculates a shotpattern necessary to ablate to the desired degree of correction. Themain procedure is the procedure "Search" illustrated at lines 1107 to1176 of the attached Appendix A. SHOT₋₋ PATTERN 2000 begins at step 2002where a reference array indicating the necessary degree of ablation iscalculated based on the desired amount of correction. This stepcorresponds to the procedure "FillReferenz", called at line 1145 andfound at lines 314 to 378 of the attached Appendix A. This procedurecreates a reference array indicating the necessary degree of ablation ateach point of the treatment area to accomplish the desired degree ofcorrection. It will be understood to those of ordinary skill in the artwhat the particular degree of ablation necessary to correct forhyperopia or myopia is, and in any case, the necessary equations arefound in this specification.

Then, SHOT₋₋ PATTERN 2000 proceeds to step 2004, where it creates shotrings. This corresponds to the procedure "Verteilen", which is called atline 1161 and is shown at lines 394 to 462 of the attached Appendix A.This procedure partitions the spirals or rings into a maximum of 32rings.

Proceeding to step 2006, the spot sizes for each of the rings is thencalculated by a procedure "BlendenVorbelegung". Using fixed spot sizes,this will of course result in the same spot sizes for all of the rings."BlendenVorbelegung" is called at line 1162 of the attached Appendix A,and is shown at lines 523 to 563.

SHOT₋₋ PATTERN 2000 then proceeds to step 2008, where it determines thecorrect distance of the rings from the treatment center. It does so bycalling a procedure "Search Rings" at step 1163, which is shown at lines641 to 969. This is an empirical algorithm for determining the optimaldistance of each ring from the center.

Certain of the variables used by SHOT₋₋ PATTERN 2000 as illustrated inthe attached Appendix A deserve further discussion. DAT₋₋ ALL.RHOMAX isa variable in a structure DAT₋₋ ALL, which holds the information aboutthe current treatment. DAT₋₋ ALL.RHOMAX is a radius of the correctedzone, and typically has a value of 2.5 mm. DAT₋₋ ALL.SPH₋₋ CORR is thedesired spherical correction in diopters, and typically has a value offrom -5 to +5. DAT₋₋ ALL.VEKTORLAENGE is the length of the treatmentvector, which equals the total number of shots and typically has a valuebetween 200 and 1500.

SYSDATA.RATE is the ablation per shot. It is typically 0.25 microns, andis machine dependent.

VOLTHEO is the ablation volume of a certain treatment. For example, fora correction of -5.0 diopters within a treatment area with 5 mmdiameter, the value is about 0.5 mm³. This value is used in the constantspot mode to determine the "best" spot size using an empirical formula.

The structure RING holds all the information necessary for a particularring of shots. The smallest treatment element is a "ring". The empiricalalgorithm can use up to 32 "rings", and it searches for the best ringvalues. RING.DIST is the mean radius of the ring. RING.SPOT is the spotsize for shots used in this ring. RING.COUNT is the number of shots inthis ring.

For myopia, the algorithm starts with all shots distributed to identicalrings set to a radius of zero. The algorithm then increases the diameterof the rings one by one to get to the closest reference ablationfunction. For hyperopia, all rings are initially set to 7 mm in diameterand then decrease one by one to get closest to the hyperopia referenceablation function. Thus, the radii of the rings are empiricallydetermined.

MICRO, MAXABL, and ABLSHOT are integer values of various floating pointnumbers used to speed up the routine. Because the algorithm is asearching algorithm requiring much computational power, the speed isdramatically increased by using integer calculation.

Using these algorithms, a large spot size provides for a greater amountof ablation per shot, while at the same time permitting virtually anytreatment pattern to be achieved. A relatively large spot size would be2.0 mm, thus providing for relatively large coverage of treatment areaper shot. It will be appreciated that using such large spot sizes,however, the shots are generally not "adjacent" to each other, butinstead overlap to generate the desired degree of ablation at aparticular point. It is the calculation of the result of the overlappingshots that is technically challenging and relies on the empiricalalgorithm described. This is especially true when using a fixed spotsize that is relatively large in relation to the treatment area. It willfurther be appreciated that by using a fixed spot size, the diaphragm 36can be replaced by simpler equipment that requires less maintenance andadjustment. This is another advantage of using the large, fixed spotsize of overlapping shots.

Turning to FIG. 28, an alternative method of calculating treatmentpatterns using large, fixed spot sizes distributed throughout thetreatment area is shown, as well as the use of shot sorting to decreasethermal effects. A routine DITHER₋₋ SHOTS 2100 provides for both thisshot dithering as well as the sorting. The shot dithering of FIG. 28 isachieved by the program shown in Appendix B, while the sorting isachieved by the program shown in the attached Appendix C.

Proceeding to step 2102, DITHER₋₋ SHOTS 2100 performs a case statementdepending on the type of shot dithering desired. A number of differenttypes of shot dithering are shown in the program attached as Appendix B,and these distribute the shots throughout the treatment area in aslightly different way.

This case statement is performed in the attached Appendix B at lines 547to 554. If it is desired to perform a rectangular dithering, indicatedby the type of dithering being "RECTANG", DITHER₋₋ SHOTS 2100 calls aroutine at step 2104 in which the treatment is performed by dithering ina rectangular spiral. This corresponds to the procedure "DO₋₋ DITHER₋₋RECT" in the attached Appendix B, at lines 26 through 93.

If it is desired to perform a first type of circular dithering in aspiral, indicated by the type of dithering being "CIRCLE1", DITHER₋₋SHOTS 2100 proceeds to step 2106, where a routine is called that dithersin a circular spiral. In Appendix B. this corresponds to the procedure"DO₋₋ DITHER₋₋ CIRCULAR", shown at lines 97 through 179.

If it is desired to perform a slightly different type of circulardithering, indicated by type equaling "CIRCLE2" A at step 2102, DITHER₋₋SHOTS 2100 proceeds to step 2108, where it dithers in a modifiedcircular spiral. The routine for accomplishing this is the procedure"DO₋₋ DITHER₋₋ CIRCULAR2" shown in Appendix B at lines 183 through 279.This procedure works in a similar manner to that of the program ofAppendix A illustrated in FIG. 27.

If it is desired to perform a line-by-line oriented dithering, indicatedby type equalling "LINE" at step 2102, DITHER₋₋ SHOTS 2100 proceeds tostep 2110, where a routine is called that dithers line by line. Thisroutine is shown as procedure "DO₋₋ DITHER₋₋ XY" at lines 283 through395 of the attached Appendix B.

If an alternative form of dithering is desired, as indicated by typeequalling "DITHERC" at step 2102, DITHER₋₋ SHOTS 2100 proceeds to step2112, where this alternative method is used. This is found as theprocedure "DO₋₋ DITHER₋₋ C" in Appendix B at lines 399 through 515.

Using a variety of shot dithering methods, an array of shots is createdfor a fixed spot size spread over a treatment area to correct to thedesired degree of ablation.

DITHER₋₋ SHOTS 2100 then proceeds to step 2114, where it determineswhether a sorting of the shots is desired. If not, DITHER₋₋ SHOTS 2100proceeds to step 2116, where it returns to the software controlling theexcimer laser system with a shot array suitable for correcting to thedesired degree. If at step 2114 sorting is desired, DITHER₋₋ SHOTS 2100instead proceeds to step 2116, where it determines whether randomsorting is desired.

Random sorting will statistically decrease overall heating during thetreatment. Although there will typically be some overlap from shot toshot, statistically, different portions of the treatment area will beablated within a given period of time, rather than one portion of thetreatment area being continuously ablated. If at step 2116 it is desiredto randomly sort, control proceeds to step 2118, where DITHER₋₋ SHOTS2100 randomly sorts the shots. This is performed by the program attachedas Appendix C at lines 40-52.

If at step 2116 it is desired to not randomly sort, but instead to sortfor maximum displacement between shots, control proceeds to step 2120,where DITHER₋₋ SHOT 2100 sorts into a spiral pattern, as illustrated inthe attached Appendix C by the procedure "SORT₋₋ SPIRAL", shown at lines21-38. From steps 2120 and 2118, control then returns to a callingprocedure in the excimer laser system at step 2116.

In this way, a shot dither treatment is achieved, and the shots aresorted in a way to minimize thermal heating. It will be appreciated thatthe sorting could be provided also with the software illustrated in FIG.27 and attached as Appendix A.

The foregoing disclosure and description of the invention areillustrative and explanatory thereof, and various changes in the size,shape, materials, components, circuit elements, and optical components,as well as in the details of the illustrated system and construction andmethod of operation may be made without departing from the spirit of theinvention. ##SPC1##

What is claimed is:
 1. An apparatus for shaping the cornea by removingtissue from a region of the cornea that has an area to be subject toablation to a desired treatment pattern, the area having a centralpoint, the apparatus comprising:a laser that emits a laser beam having asuitable wavelength; an optical system coupled to said laser thatreceives the laser beam and images the laser beam onto the cornea; meanscoupled to the optical system for directing the optical system toprovide the laser beam at a fixed spot size on the cornea, wherein thefixed spot size is a relatively large fraction of the area of the corneato be subject to ablation; and means coupled to the laser and the meansfor directing the optical system for directing said laser to fire thelaser beam and the optical system to image the laser beam in a series ofshots at said fixed spot size, said series of shots including shotsbeing centered at at least two distances from the central point, saidseries of shots including shots partially overlapping with prior shots,and said series of shots ablating the cornea to the desired treatmentpattern, wherein said means for directing the optical system to providethe laser beam at a fixed spot size further comprises means forproviding the laser beam at a spot size fixed between 2.0 mm and 3.5 mmin diameter.
 2. A method of controlling a laser system, the laser systemincluding a laser that emits a laser beam having a suitable wavelengthand the laser system including an optical system that images the laserbeam onto a cornea that has an area to be subject to ablation to adesired treatment pattern, the area having a central point, the methodcomprising the steps of:calculating a shot sequence to ablate the corneato the desired treatment pattern; sorting said calculated shot sequence;and directing the laser system to fire the laser beam in a series ofshots, said series of shots corresponding to and fired in order of saidsorted calculated shot sequence, wherein said sorting step furthercomprises the step of randomly sorting said calculated shot sequence. 3.The method of claim 2, wherein said sorting step further comprises thestep of sorting said calculated shot sequence into a spiral.
 4. A methodof controlling a laser system, the laser system including a laser thatemits a laser beam having a suitable wavelength and the laser systemincluding an optical system that images the laser beam onto a corneathat has an area to be subject to ablation to a desired treatmentpattern, the area having a central point, the method comprising thesteps of:directing the laser system to provide the laser beam at a fixedspot size on the cornea, wherein the fixed spot size is a relativelylarge fraction of the area of the cornea to be subject to ablation; anddirecting the laser system to fire the laser beam in a series of shotsat said fixed spot size, said series of shots including shots beingcentered at at least two distances from the central point, said seriesof shots including shots partially overlapping with prior shots, andsaid series of shots ablating the cornea to the desired treatmentpattern, wherein said step of directing the laser system to provide thelaser beam at a fixed spot size further comprises the step of directingthe laser system to provide the laser beam at a spot size fixed between2.0 mm and 3.5 mm in diameter.
 5. The method of claim 4, wherein saidstep of directing the laser system to fire the laser beam in a series ofshots being centered at least two distances from the central pointfurther comprises the steps of:directing the laser system to fire aseries of overlapping shots forming a ring having a first radius fromthe central point; and directing the laser system to fire a series ofoverlapping shots forming a ring having a second radius from the centralpoint.
 6. The method of claim 4, wherein said step of directing thelaser system to fire a series of partially overlapping shots includesthe step of:firing a first shot; firing a second shot not overlappingsaid first shot; and firing a third shot partially overlapping saidfirst shot.
 7. The method of claim 4, wherein said step of directing thelaser system to fire the laser beam in a series of shots furthercomprises the steps of:dividing the series of shots among a plurality ofrings; and empirically calculating a radius for each of said pluralityof rings to satisfy the desired treatment pattern.
 8. The method ofclaim 4, wherein said step of directing the laser system to fire thelaser beam in a series of shots further comprises the stepsof:calculating a shot dithering pattern corresponding to the desiredtreatment pattern; and directing the laser system to fire the laser beamwith the series of shots corresponding to said shot dithering pattern.9. The method of claim 8, wherein said calculating step furthercomprises calculating a rectangular shot dithering pattern.
 10. Themethod of claim 8, wherein said calculating step further comprisescalculating a circular shot dithering pattern.
 11. The method of claim8, wherein said calculating step further comprises calculating aline-by-line shot dithering pattern.
 12. The method of claim 8 furthercomprising the step of:after said calculating step, sorting saidcalculated shot dithering pattern.
 13. The method of claim 12, whereinsaid sorting step further comprises the step of randomly sorting saidcalculated shot dithering pattern.
 14. The method of claim 12, whereinsaid sorting step further comprises the step of sorting said calculatedshot dithering pattern into a spiral.
 15. A method of controlling alaser system, the laser system including a laser that emits a laser beamhaving a suitable wavelength and the laser system including an opticalsystem that images the laser beam onto a cornea that has an area to besubject to ablation to a desired treatment pattern, the area having acentral point, the method comprising the steps of:directing the lasersystem to provide the laser beam at a fixed spot size on the cornea,wherein the fixed spot size is a relatively large fraction of the areaof the cornea to be subject to ablation; and directing the laser systemto fire the laser beam in a series of shots at said fixed spot size,said series of shots including shots being centered at at least twodistances from the central point, said series of shots including shotspartially overlapping with prior shots, and said series of shotsablating the cornea to the desired treatment pattern, wherein said stepof directing the laser system to fire the laser beam in a series ofshots further comprises the steps of:dividing the series of shots amonga plurality of rings; and empirically calculating a radius for each ofsaid plurality of rings to satisfy the desired treatment pattern.
 16. Amethod of controlling a laser system, the laser system including a laserthat emits a laser beam having a suitable wavelength and the lasersystem including an optical system that images the laser beam onto acornea that has an area to be subject to ablation to a desired treatmentpattern, the area having a central point, the method comprising thesteps of:directing the laser system to provide the laser beam at a fixedspot size on the cornea, wherein the fixed spot size is a relativelylarge fraction of the area of the cornea to be subject to ablation; anddirecting the laser system to fire the laser beam in a series of shotsat said fixed spot size, said series of shots including shots beingcentered at at least two distances from the central point, said seriesof shots including shots partially overlapping with prior shots, andsaid series of shots ablating the cornea to the desired treatmentpattern, wherein said step of directing the laser system to fire thelaser beam in a series of shots further comprises the stepsof:calculating a shot dithering pattern corresponding to the desiredtreatment pattern; and directing the laser system to fire the laser beamwith the series of shots corresponding to said shot dithering pattern.17. The method of claim 16, wherein said calculating step furthercomprises calculating a rectangular shot dithering pattern.
 18. Themethod of claim 16, wherein said calculating step further comprisescalculating a circular shot dithering pattern.
 19. The method of claim16, wherein said calculating step further comprises calculating aline-by-line shot dithering pattern.
 20. The method of claim 16 furthercomprising the step of:after said calculating step, sorting saidcalculated shot dithering pattern.
 21. The method of claim 20, whereinsaid sorting step further comprises the step of randomly sorting saidcalculated shot dithering pattern.
 22. The method of claim 20, whereinsaid sorting step further comprises the step of sorting said calculatedshot dithering pattern into a spiral.
 23. A method of controlling alaser system, the laser system including a laser that emits a laser beamhaving a suitable wavelength and the laser system including an opticalsystem that images the laser beam onto a cornea that has an area to besubject to ablation to a desired treatment pattern, the area having acentral point, the method comprising the steps of:directing the lasersystem to provide the laser beam at a fixed spot size on the cornea,wherein the fixed spot size is a relatively large fraction of the areaof the cornea to be subject to ablation; and directing the laser systemto fire the laser beam in a series of shots at said fixed spot size,said series of shots including shots being centered at at least twodistances from the central point, said series of shots including shotspartially overlapping with prior shots, and said series of shotsablating the cornea to the desired treatment pattern, wherein said stepof directing the laser system to fire a series of partially overlappingshots includes the step of:firing a first shot; firing a second shot notoverlapping said first shot; and firing a third shot partiallyoverlapping said first shot.